Open access Research

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To what extent are GCS and AVPU
equivalent to each other when assessing
the level of consciousness of children
with head injury? A cross-sectional
study of UK hospital admissions.
Amy GL Nuttall, Katie M Paton, Alison M Kemp

To cite: Nuttall AGL, Paton KM, Abstract

Kemp AM. To what extent are
GCS and AVPU equivalent to
each other when assessing
the level of consciousness of
children with head injury? A
cross-sectional study of UK
hospital admissions.. BMJ Open
2018;8:e023216. doi:10.1136/
bmjopen-2018-023216
►► Prepublication history and
additional material for this
paper are available online. To
view these files, please visit
the journal online (http://​dx.​doi.​
org/​10.​1136/​bmjopen-​2018-​
023216).
Received 28 March 2018
Revised 9 July 2018
Accepted 19 September 2018
© Author(s) (or their
employer(s)) 2018. Re-use
permitted under CC BY-NC. No
commercial re-use. See rights
and permissions. Published by
BMJ.
Division of Population Medicine,
Cardiff University, Cardiff, UK
Correspondence to
Dr Alison M Kemp;
​KempAM@​cardiff.a​ c.​uk
Objective  To evaluate utility and equivalence of Glasgow
Coma Scale (GCS) and the Alert, Voice, Pain, Unresponsive
(AVPU) scale in children with head injury.
Design  Cross sectional study.
Setting  UK hospital admissions: September 2009–
February 2010.
Patients  <15 years with head injury.
Interventions  GCS and/or AVPU at injury scene and in
emergency departments (ED).
Main outcome  Measures used, the equivalence of AVPU
to GCS, GCS at the scene predicting GCS in ED, CT results
by age, hospital type.
Results  Level of consciousness was recorded in 91%
(5168/5700) in ED (43%: GCS/30.5%: GCS+AVPU/17.3%:
AVPU) and 66.1% (1190/1801) prehospital (33%:
GCS/26%GCS+AVPU/7%: AVPU). Failure to record level
of consciousness and the use of AVPU were greatest for
infants. Correlation between AVPU and median GCS in
1147 children <5 years: A=15, V=14, P=8, U=3, for 1163
children ≥5 years: A=15, V=13, P=11, U=3. There was no
significant difference in the proportion of infants who had
a CT whether AVPU=V/P/U or GCS<15. However diagnostic
yield of intracranial injury or depressed fracture was
significantly greater for V/P/U than GCS<15 :7/7: 100%
(95% CI 64.6% to 100%) versus 5/17: 29.4% (95% CI
13.3% to 53.1%). For children >1 year significantly more
had a CT scan when GCS<14 was recorded than ‘V/P/U
only’ and the diagnostic yield was greater. Prehospital GCS
and GCS in the ED were the same for 77.4% (705/911).
Conclusion  There was a clear correlation between Alert
and GCS=15 and between Unresponsive and GCS=3 but
a wider range of GCS scores for responsive to Pain or
Voice that varied with age. AVPU was valuable at initial
assessment of infants and did not adversely affect the
proportion of infants who had head CT or the diagnostic
yield.
Introduction   National Institute for Health and Care
An estimated 30 000 children are admitted
to hospitals in England annually with head
injury.1 Although the majority of injuries
are mild with a low mortality rate (<0.5%),
Strengths and limitations of this study
►► This is the largest study to explore the equivalence
of AVPU to Glasgow Coma Scale (GCS) in children
admitted to hospital with head injury.
►► It is the only study to date to compare the outcomes
for AVPU and GCS in children with head injury.
►► The retrospective, multicentre design may limit find-
ings due to impaired completeness and variation in
data quality.
►► Study numbers are limited by the lower numbers of
children with severe loss of consciousness, however
this represents real world epidemiology.
an estimated 15%–20% have moderate to
severe traumatic brain injury.2 Children
with impaired levels of consciousness have
the greatest risk of significant morbidity or
mortality.2 3 Clinicians rely on scores, such as
the Glasgow Coma Scale (GCS) to evaluate
levels of consciousness to identify children
who need further investigation and early
intervention.4
Teasdale and Jennet devised the GCS in
1974 (modified in 1976)4 5 (online supple-
mentary table 1). It scores levels of neurolog-
ical dysfunction in three components; motor,
verbal and eye opening responses that are
considered separately and combined into an
overall score. Evaluating levels of conscious-
ness in young children is challenging due to
their limited verbal and motor responses, and
several adaptations to the GCS for <5 years
olds have been proposed.6 UK head injury
guidelines recommend the paediatric GCS
(pGCS) for infants <1 year old.3 7
Excellence (NICE) guidelines from 2003
to 2014 recommend that all children with a
head injury have a GCS recorded at prehos-
pital assessment and when seen in emergency

Nuttall AGL, et al. BMJ Open 2018;8:e023216. doi:10.1136/bmjopen-2018-023216 1

Open access
departments (ED), that infants have a CT scan when GCS
is <15 and for the older children CT is recommended
when GCS<143 Ambulance staff, ED and child health
clinicians receive regular updated training in its appli-
cation. The score provides a baseline to facilitate triage,
monitor levels of consciousness and aid decisions about
whether CT imaging is required, the level of care and
need for specialist involvement. However, studies have
identified high levels of inter-rater variability, and vari-
ability in outcome prediction based on GCS.8 9
The complexity of the GCS compared with other
simpler scores raises concerns about its utility10 and alter-
native shorter scores are used. The AVPU score (online
supplementary table 1) was introduced by the Amer-
ican College of Surgeons11 to monitor the patients with
poisoning.12 It is less detailed and has four broad scores,
A, Alert; V, responsive to Verbal stimulus; P, responsive to
Painful stimulus; U, Unresponsive. No formal training is
required to administer this score and it can be used easily
at the site of injury.13
The Confidential Enquiry into Head Injury in Child-
hood was the principal project within the Centre for
Maternal and Child Enquires (CMACE) collected data
from hospital admissions for head injury across the UK.
This large dataset provided the opportunity to evaluate
the clinical practice of recording levels of consciousness
for children with head injury.
This study aims to describe the utilisation of GCS
and AVPU in children with head injury, to determine
the correlation between AVPU and GCS scores for chil-
dren older and those younger than 5 years of age and
to explore whether the scoring system that is used to
measure of level of consciousness affects the rate of CT
scan and subsequent diagnostic yield.
Methods
Data were collected from the case notes of children up to
15 years of age admitted to hospital for more than 4 hours
following a head injury between September 2009 and
February 2010. Ninety per cent of hospitals that admit chil-
dren for head injury in England, Wales, Northern Ireland
and the Channel islands participated in the study.14 Chil-
dren with superficial or facial injuries that were unlikely
to be associated with brain injury were excluded. The data
collection proformas were designed to follow the child’s
pathway of care and to obtain information that was avail-
able from the child’s hospital records. Proformas (online
supplementary figure 1a,b) were completed by local head
injury enquiry coordinators (previously identified in each
hospital) and entered onto a secure CMACE database
and placed in SPSS Statistics V.19 for analysis.
Data were collected for each child for GCS total and
component scores, AVPU score, age, the type of hospital
to which the child was admitted (specialist hospitals were
defined as designated children’s hospital, or those that
became major trauma centres in 2012 and general hospi-
tals, were those that had none of these facilities), whether
2 Nuttall AGL, et al. BMJ Open 2018;8:e023216. doi:10.1136/bmjopen-2018-023216
BMJ Open: first published as 10.1136/bmjopen-2018-023216 on 28 November 2018. Downloaded from http://bmjopen.bmj.com/ on February 4, 2020 by guest. Protected by copyright.
or not the children received a CT scan and the diagnostic
yield of intracranial abnormality or depressed fracture.
Analysis
We describe the proportion of children <15 years who
had their level of consciousness recorded using GCS or
AVPU respectively in the prehospital setting and at the
first clinical assessment at ED. We have calculated the
median and IQR of GCS scores for each aspect of AVPU
to determine the correlation between GCS and AVPU for
children <5 years old and those >5 where both scores were
applied.
We compared the proportion of CT scans undertaken
and the CT findings, between children who had their level
of consciousness measured using AVPU, those measured
with GCS and those where both scores were recorded to
determine whether there was any difference according to
the method used to record level of consciousness. This
was undertaken for children <1 year and those >1 year as
NICE guidelines lines for when a head CT scan should be
undertaken vary for these two age groups3: for infants, a
CT scan is recommended in those where GCS<15, where
AVPU only was recorded we extrapolated that this should
be equivalent of a V/P/U. For older children the recom-
mendation is for a CT scan if GCS<14, again we chose a
cut-off of V/P/U when GCS was not recorded.
We described the association between prehospital GCS
and GCS in the ED to determine the extent of change
between ambulance recorded GCS and that on admis-
sion. All analyses were undertaken using the online tool
Vassar Stats15 to calculate 95% CIs of proportion based on
continuity-corrected versions of the Wilson interval. Fish-
er’s exact test was used to calculate levels of significance
at p<0.05.
Patient and public involvement
This was an analysis undertaken from data collected for
the National Child Health Outcome review on head inju-
ries, based on a National Health Service priority. Both
patients and professionals were consulted during design
of the study proformas. Patient recruitment was via anony-
mised case note review, with ethical and CAG approvals.
The overall study findings have been disseminated in a
publicly available report.
Results
Overall, 5700 children were included in the study,
median age 49 months, 61.4% (3500) were boys (online
supplementary figure 2), 1801 children were transported
to hospital by ambulance and 385 were transferred on to
a second hospital (data were available for 318 of these
latter cases).
Overall 90.6% (5168/5700) of children had their
consciousness level recorded in the ED at the first hospital
to which they were admitted, as did 85% (271/318) of
children who were transferred to a second hospital, 66.1%
(1190/1801) of the children transported to hospital by

Table 1  The proportion of children (n=5700) who had GCS or AVPU recorded in prehospital setting and on admission to
subsequent hospitals.
GCS only % (95% CI) (n) GCS and AVPU % (n)
Prehospital 33.0% 25.9%
assessment (594) (467)
Hospital assessment 42.9% 30.5%
in ED (2443) (1739)
Second hospital 47.2% 29.6%
assessment on (150) (94)
admission
Total 3187 (40.7%) 2300 (29.4%)
ED, emergency departments; GCS, Glasgow Coma Scale.
ambulance had their consciousness level recorded at the
scene of the incident (table 1).
The proportion of children who had an ‘AVPU only’
or no recording was higher for younger children and
decreased with age, whereas the proportion of children
who had a ‘GCS only’ increased with the age (figure 1).
Overall 73.5% (4426/6018) of child hospital attendances
had a GCS recorded. Of the total 5487 GCS recorded only
75.4% (4137) had the component scores documented.
Children were first taken to a general hospital in 83.6%
(4768) of cases, and specialist hospitals in the remainder.
The specialist hospitals recorded an APVU in significantly
fewer cases than the general hospitals (13.6%: 95% CI 11.6%
to 16.0% vs 18%: 95% CI 16.9% to 19.1%) (figure 1).
Correlation between AVPU and GCS
In the complete dataset 2300 children had both AVPU and
GCS recorded at the same point of care. Of these AVPU
scores, 91.4% (2102)=A, 4% (92)=V, 2% (47)=P and 2.6%
(59)=U. The correlation between AVPU and GCS differed
between the 1137 children <5 years and those ≥5 years old
(n=1163). For children <5 years, the median scores and
IQRs were A=15 (IQR 0), V=14 (IQR 13–15), P=8 (IQR
6–9) and U=3 (IQR 3–6) (online supplementary figure
3a). There was no significant difference within this age
band between those younger and those >1 year of age. For
children of ≥5 years, the median scores were A=15 (IQR
0), V=13 (IQR 12–14), P=11 (8 to 12) and U=3 (IQR 3–5)
(online supplementary figure 3b).
For children <1 year and those >1 year, was there any
difference between the proportion of CT scans performed and
the diagnostic yield according to the method of recording the
level of consciousness?
Table 2 shows that there was no statistically significant
difference between the proportion of CT scans under-
taken in the three groups of infants, (i) with a GCS<15,
(ii) where the AVPU score was V/P/U or (iii) those with
a recorded AVPU=V/P/U and a GCS<15. While numbers
were small, significantly more infants with AVPU=V/P/U
or V/P/U and GCS<15 had intracranial injury (ICI) or
depressed fracture on CT than those who had a GCS<15
(p<0.01). When infants were Alert and/or GCS was 15,
Nuttall AGL, et al. BMJ Open 2018;8:e023216. doi:10.1136/bmjopen-2018-023216
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AVPU only % (n) Not recorded % (n) Total
7.2% 33.9% 1801
(129) (611)
17.3% 9.3% 5700
(986) (532)
8.5% 14.8% 318
(27) (47)
1142 (14.6%) 1190 (15.2%) 7819
10.2%–23.8% of children who had a CT scan had an
abnormality identified.
For the older children, a significantly greater propor-
tion of children had a CT when the GCS was <14, or the
AVPU was V/P/U and GCS<14 than when the AVPU only
was recorded as V/P/U (p<0.001). The diagnostic yield
was significantly greater in these two groups than when
AVPU only was recorded (table 2). For children who were
Alert and/or who had a GCS=14/15, 7.6%–12.4% who
had a CT scan had an abnormality.
When both AVPU and GCS were recorded and there
was an apparent discrepancy between the scores (ie, Alert
with a GCS<15 or GCS of 15 and AVPU=V/P/U), it was
not possible to determine what influenced the decision
to undertake a CT scan.
To what extent does GCS recorded at the scene of injury
reflect the GCS on admission?
The GCS at the scene had a positive predictive value (PPV)
of 77.4% (705/911) for the same GCS in the ED. The PPV
for a GCS of 15 on hospital admission for children with a
prehospital GCS of 15 was 88.6%. Thus 11.3% (73) of chil-
dren with a GCS of 15 at the scene had deteriorated by the
time their GCS was recorded in ED. All 13 children who died
had a GCS of ≤8 at the scene. GCSs≤14 had a PPV of 71%
(191/269) for GCSs≤14 on admission (table 3).
Discussion
The consciousness level was documented in 90% of chil-
dren admitted to hospital with head injury. Overall the
majority of hospital and prehospital admissions had a
GCS recorded. While this is in keeping with current NICE
guidelines,3 it was not universal practice and 30% of assess-
ments reported in this study used either AVPU only or
had no measure of conscious state recorded. The AVPU
was most frequently used for infants <1 year old, while the
GCS was used more frequently in older children. This
finding is likely to be due to difficulties applying the GCS
in infancy, despite the pGCS that is designed to account
for these limitations.
3
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Figure 1  Proportion of children who had level of consciousness recorded and methods used in first hospital attended, by age
group (<1, 1–4, 5–9, 10–14 years) and by specialist or general hospitals. (AVPU only: n=986; GCS only: n=2443; GCS and AVPU:
n=1739; no recording: n=532, eight children excluded as age was not recorded.) GCS, Glasgow Coma Scale; hosp., hospital.

The use of the ‘AVPU only’ in infancy (<1 year) did not
adversely affect the clinical management or diagnosis in
terms of the proportion of children who had CT head
scans undertaken and the diagnostic yield. Indeed, it
could be argued that the AVPU=V/P/U was a more
specific measure of serious head injury in this age group,
as a significantly greater proportion of the children with
a recorded AVPU=V/P/U had an ICI or a depressed frac-
ture on CT scan when compared with cases where ‘GCS
only’ was applied. However, among older children the
GCS was a better predictor of an abnormal CT as in those
with a GCS<14, significantly more children had a CT scan
and significantly more of these scans were abnormal than
when V/P/U only was recorded. The level of conscious-
ness is not the only factor to influence the decision to
undertake a CT scan.3 This study confirms that an esti-
mated 1 in 5–10 children with no impaired consciousness
had an abnormality on CT. Influential factors for the
same series of children are described further in Kemp
et al.16 However, these results would support the inclu-
sion of AVPU as an acceptable initial measure of level of
consciousness in infants and support a recommendation
that a CT scan should be undertaken if AVPU=V/P/U.
The AVPU is simple, but none of the components are
clearly defined. When considering the theoretical equiv-
alence of AVPU to the components of the GCS, there is a
range of total GCS that could be equivalent to each AVPU
component. The definitions of eye opening scores (E1-4)
can be directly related to the AVPU responses. However,
an Alert child could be equivalent to a GCS of 15 or 14 as

4 Nuttall AGL, et al. BMJ Open 2018;8:e023216. doi:10.1136/bmjopen-2018-023216

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Table 2  The number and proportion of children who had a CT scan when either an ‘AVPU only’ (n=986) ‘GCS only’ (n=2443)
or both scores (n=1739) were recorded in ED and number and proportion of ICI or depressed fractures in those who had head
CT
No % (95% CI) of those
No % who had CT with who had CT with ICI or
Children (n) 95% CI Unknown depressed fracture
<1 year of age
 AVPU Alert 358 63 3 15/63
 n=375 17.6% (14% to 21.9%) 23.8% (15% to 35.6%)
V/P/U 17 7 0 7/7
41.2% (21.6% to 64%) 100% (64.6% to 100%)
 GCS 15 269 59 5 13/59
 n=301 21.9% (17.4% to 27.3%) 22% (13.4% to 34%)
 
<15 32 17 0 5/17
53.1% (36.5% to 69.1%) 29.4 (13.3% to 53.1%)
 AVPU and Alert/GCS=15 247 59 1 6/59
GCS 23.9% (19.0% to 29.6%) 10.2% (4.8% to 20.5%)
 n=270 Discrepant scores 16 5 2/5
Alert/GCS<15 (n=14) 31.3% (14.2% to 55.6%) 40% (11.8% to 76.9%)
or GCS 15 and V/P/U
(n=2)
V/P/U: GCS<15 7 5 5/5
71.4% (36.0% to 92.0%) 100% (56.6% to 100%)
>1 year
 AVPU Alert 581 108 5 10/108
 n=610 18.6% (15.6% to 21.9%) 9.3% (5.1% to 16.2%)
V/P/U 29 13 0 0/13
44.8% (28.4% to 64.5%) 0% (0% to 22.8%)
 GCS 14–15 1964 630 29 78/630
 n=2138 32% (30% to 34.2%) 12.4% (10% to 15.2%)
<14 174 145 1 44/145
83.3% (77.1% to 88.1%) 30.3% (23.4% to 38.3%)
 AVPU and Alert/GCS=14 or 15 1338 406 15 31/406
GCS 30.7% (28.3% to 33.2%) 7.6% (5.4% to 10.6%)
 n=1466
Discrepant scores 66 42 0 3/42
Alert/GCS<14 (n=27) 63.6% (51.6% to 74.2%) 7.1% (2.5% to 19.0%)
or GCS 14 or 15/and V/P/U
(n=39)
V/P/U: GCS<14 62 45 0 18/45
72.6% (60.4% to 82.1%) 40% (27% to 54.6%)
Italics highlight the results were there was discrepancy between GCS and AVPU scores.
*Eight children excluded as age was unknown (one from AVPU group and four from GCS group, three from group with both scores).
ED, emergency departments; GCS, Glasgow Coma Scale; ICI, intracranial injury; P, responsive to painful stimulus; U, unresponsive; V,
responsive to verbal stimulus.

they may be Alert but confused and have a verbal score of
V4, however a verbal response would only be detectable
in >5 year where the unmodified GCS is advised. An Unre-
sponsive child should score an E1 and V1, however the
motor response may include M3 as they may be decorti-
cate or decerebrate. Therefore, the theoretical range for
U could be a GCS 3–5.
It is less easy to align Verbal or Pain responsive cate-
gories of AVPU to GCS component scores due in part to
the difference in pGCS and adult GCS. While the GCS
component descriptors for the <5 year olds are more
specific than for the older age group in terms of respon-
siveness there is still considerable scope for matching
against different scores. For example, a child <5 years who
responds to pain may score E2 for eye opening, V2-V3 for
a verbal score and M2-5 for motor, that is, a total score
between 6 and 10 while for a child >5 years the corre-
sponding scores could be E2, V2-V5, M2-M5 totalling a
score between 6 and 12. These wide ranges are reflected
in the study results. Due to the large variability of V/P on

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GCS is a composite scoring system of three components
Table 3  GCS at the scene and in the ED for 911 children
where both were recorded  which share no relationship and there are many clini-
cally plausible score combinations.19 It is important to
Total GCS
GCS ED ≤8 9–12 13–14 15 remember that the total GCS cannot be seen as a static and
at scene
exact scale like the simpler scores and it should be used to
GCS scene measure change in each of its components with the total
  15 4 5 64 570 643 score to track the progress and consciousness of a patient.
 13–14 4 13 81 56 154 This emphasises the need for correct practice using the
 9–12 8 16 11 8 43 score, stating the component scores alongside total GCS
on every communication and documentation as recom-
 ≤8  or died 38 12 7 14 71
mended by NICE. In this study only 75.4% of GCS scores
 Total GCS 54 46 163 648 911 had the component scores listed. This, however, does not
in ED
take away the validity of using the total score as a guide-
Shaded values, highlight where the GCS was the same in at the line for the clinical management, that is, when a CT scan is
scene and in ED. recommended or appropriate airway intervention and the
ED, emergency departments; GCS, Glasgow Coma Scale. involvement of an anaesthetist.3
Prehospital GCS is a reasonable indicator of GCS in EDs
the GCS, the AVPU is not sufficiently precise to closely and may be helpful in determining which children are at
monitor neurological deterioration. risk of serious head injury and require direct transfer to
Table 4 lists published studies that compare GCS with major trauma facilities, either in isolation or as part of a
AVPU scores. The majority support a clear correlation composite tool to be used in such situations.
between Alert and GCS=15 and Unresponsive with GCS=3 However, for one in four children the GCS will change
with a wider range of associated GCS scores for responsive by the time they reach ED and ongoing monitoring with
to Pain or Voice. There are only two smaller paediatric GCS in the prehospital period including all component
studies.17 18 The most recent of which evaluated the use of scores is essential.
AVPU in the prehospital setting to identify children who This study is the largest one to explore the equivalence
might require intubation or intensive care and concluded of AVPU to GCS in children admitted to hospital with
that an AVPU of A or V identified 100% of children with a head injury, and the only one that attempts to compare the
pGCS of or exceeding eight, and therefore, at low risk of outcome for the two scoring systems in terms of investigations
requiring intubation or intensive care treatment.18 and diagnostic yield of serious cranial and ICI. The findings

Table 4  Previously published studies and equivalence of GCS and AVPU

A V P U
13
Mackay n=174,730 Most common 15 (9–15) 12 (5–14) 8 (4–13) 3 (3–7)
Ambulance transfers to emergency score (range)
departments
Age>5 years
McNarry20 n=1000 Median score 15 13 8 6
Neurosurgical patients
All ages
Kelly21 Median (IQR) 15 (15) 13 (12–14) 8 (7–9) 3 (3)
n=1384
Hospital admissions for poisoning
All ages
Raman17 Median (IQR) 14 (12–15) 11 (10–12) 6 (5.5–8) 3 (3–4)
n=159
Paediatric patients admitted to
paediatric intensive care unit
Age 2 months–12 years
Hoffman18 Median (IQR) 15 (15) 12 (10–13) 8.5 (6–10) 3 (3)
n=302
Children prehospital emergencies
multiple diagnoses
Age<10 years
Nuttall (2018) Median (IQR) 15 (15) 13 (12–14) 11 (8–12) 3 (3–5)
n=5700
Age 5–15 years

6 Nuttall AGL, et al. BMJ Open 2018;8:e023216. doi:10.1136/bmjopen-2018-023216


are limited by its retrospective and multicentre design that
may have impaired data completeness and variation in data
quality between centres. Data were extracted from hospital
case notes and while there may have been administrative
errors that explained outlying results, clinical governance
should ensure a level of accuracy within the case notes. We
were unable to follow-up children who did not have CT and
identify potentially missed cases of ICI or depressed fracture.
While it was stated that measures were taken at the same
point in the care pathway, we cannot be sure that temporal
differences did not have an effect. Study numbers in this
field will always be limited by the lower numbers of children
with severe loss of consciousness, however this represents the
real-world epidemiology of head injury where the majority of
cases seen are minor head injuries.
Conclusion
Despite the current NICE guidelines, 25% children with
head injury did not have a GCS recorded in the ED rising
to 40% of prehospital cases. This study found that the
equivalence of AVPU to GCS varied between children
<5 years and >5 years. The use of AVPU alone at the
initial hospital assessment in infancy did not adversely
affect the rate of initial neuroradiological investigation
or diagnostic yield. When used in isolation in older chil-
dren it predicted a lower rate of CT imaging and lower
diagnostic yield. We would recommend that use of the
simple AVPU is beneficial to initial assessment of infants
with head injury but is not sensitive enough to monitor
change in levels of consciousness and would, therefore,
not be recommended for ongoing monitoring of clinical
status in this age group.
Acknowledgements  Members of the original and subsequent CMACE Head
Injury External advisory group: Professor Robert Tasker, Paediatrics, University
of Cambridge; Dr Rosemary Arthur, Consultant Paediatric Radiologist, Leeds
(British Society Paediatric Radiology); Mr Richard Edwards MD, Department of
Neurosurgery, Bristol Hospital for Children; Ms Rosie Houston Research fellow
CMACE; Dr Phillip Hyde MBBS, Paediatric Intensive Care Unit, Southampton
Children’s Hospital; Dr Ian Maconochie PhD, Imperial College NHS Healthcare Trust,
London, UK, Dr Fiona Lecky, Research Director TARN, Senior Lecturer, Honorary
Consultant Emergency Medicine, Manchester; Dr Fiona Moore, Medical Director
London Ambulance Service; Dr Kevin Morris, Director PICU Birmingham Children’s
Hospital; Dr Roger Parslow PhD, Senior Lecturer in Epidemiology, Leeds Institute
of Cardiovascular and Metabolic Medicine, University of Leeds; Dr Gale Pearson
Consultant in Intensive Care, Birmingham Children’s Hospital; Lisa Turan, Chief
Executive Child Brain Injury Trust; Girkamal Virdi, Assistant Head of Clinical and
Audit Research, London Ambulance Service; Mark Woolcock, Emergency Medical
Practitioner and Emergency Specialist Service, South Western Ambulance Service,
NHS Foundation Trust.
Contributors  AN: Medical student who undertook some of the data analysis and
ran a second check on the statistical analysis undertaken by KMP. AN was lead
author and contributed to the manuscript and undertook a literature search. KMP:
Biosciences student undertook the primary data analysis, literature search and
wrote the first draft of the paper. AMK: Principal investigator on the overall analysis
of the dataset, supervised the student participation in the project. Edited, checked
and finalized the final draft.
Funding  This project/audit was commissioned and funded by the Healthcare
Quality Improvement Partnership (HQIP) Traumatic head injury in children and
young people: a national overview as part of the National Clinical Audit and Patient
Outcomes Programme (NCAPOP). This is one of a series of publications using the
study data.
Nuttall AGL, et al. BMJ Open 2018;8:e023216. doi:10.1136/bmjopen-2018-023216
Open access
BMJ Open: first published as 10.1136/bmjopen-2018-023216 on 28 November 2018. Downloaded from http://bmjopen.bmj.com/ on February 4, 2020 by guest. Protected by copyright.
Competing interests  None declared.
Patient consent  Not required.
Ethics approval  The project was approved by the Central Manchester Research
Ethics Committee (Ref 09/H1008/74) and was registered with hospital R&D or
clinical governance departments in the participating hospitals. Approvals were
renewed when the project was transferred to Cardiff University for analysis and
updated in July 2012 (Ref 09/H1008/74).
Provenance and peer review  Not commissioned; externally peer reviewed.
Data sharing statement  Primary data-set has been destroyed subject to HQIP
requirements.
Open access This is an open access article distributed in accordance with the
Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which
permits others to distribute, remix, adapt, build upon this work non-commercially,
and license their derivative works on different terms, provided the original work is
properly cited, appropriate credit is given, any changes made indicated, and the use
is non-commercial. See: http://​creativecommons.​org/​licenses/​by-​nc/​4.​0/.
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